Medical Release Form

Medical Release Form
Each team member is to complete the following medical release form.

NOTE TO TEAM COORDINATOR: The completed and signed copies of the medical release must be taken to the field or uploaded into the Teams Management system. DO NOT send these forms to the Nazarene Missions Teams office. These forms may be required by the hospital or doctor before medical assistance can be given.

If traveling outside of the U.S., please check with your site coordinator to see if this form requires a notarized signature. If it is required, your team leader will have access to this form with the notary section.
In the following sections, Please complete the information as directed by the Red Letters.

I, (Your Name), hereby give (Team Leader 1) and (Team Leader 1)permission to secure immediate medical treatment for me in the event that I am not able to make that decision due to an injury or illness
Your Name*
Team Leader 1*
Team Leader 2*
Date Permission Granted:*

MonthDayYear
Date

In the following sections, Please complete the information as directed by the Red Letters.

In the case of a minor: I, (Legal Guardian) give permission to, (Team Coordinator) to secure immediate medical treatment for my child in the event of accident or illness.

It will be from the date of (Start Date) to (End Date).
Parent/Legal Guardian*
Team Coordinator*
Starting Month- Day*
Starting Year*
Ending Month- Day*
Ending Year*

Parent/Guardian Full Name*
Signature*

Clear
State of Residence*
e.g., Alabama
County of Residence*
Your Email*
example@example.com
Global Ministry Center — 17001 Prairie Star Pkwy, Lenexa, KS, 66220, USA Nazarene Missions Teams email: missionsteams@nazarene.org
Should be Empty: